We are enhancing our authorization requirements for Medicare.
WellCare is excited to announce some important Medicare outpatient prior authorization requirement changes. We are reducing the overall amount of Medicare outpatient services/procedures requiring prior authorization for Behavioral Health services. These updates are designed to help ease your day-to-day interactions with us while allowing us to continue to exercise responsible stewardship over the government-funded healthcare programs we administer.
For dates of service on or after May 26, 2018, we are standardizing Behavioral Health authorization requirements across ALL outpatient places of service for our Medicare services. Listed below are the Behavioral Health outpatient procedure codes that will require prior authorization as of the above-mentioned date. All other covered procedure codes do not require authorization and can be rendered and billed as medically necessary.
On May 26, 2018, www.wellcare.com/auth_lookup will be updated to reflect these changes. Prior authorization requirements are subject to periodic changes. You should always use our website’s authorization page to determine whether a procedure code requires prior authorization, and always check eligibility and confirm benefits before rendering Behavioral Health services to members. Failure to do so may result in denial of reimbursement.
For questions regarding this notice, please contact Provider Services at the number located in your Quick Reference Guide. When prompted say “Authorizations” or
Thank you for your continued participation and cooperation in our ongoing efforts to render quality healthcare for our members. We look forward to helping you provide the highest quality of care for our members.
Outpatient Procedure Codes Requiring Prior Authorization as of May 26, 2018
90867 Therapeutic Repetitive Transcranial (TMS)
90868 Therapeutic Repetitive Transcranial (TMS)
90869 Therapeutic Repetitive Transcranial (TMS)
90870 Electroconvulsive Therapy
90899 Unlisted Psychiatric procedure
96101 Psychological testing
96102 Psychological testing
96103 Psychological testing
96105 Assessment of Aphasia of speech/language
96116 Neurobehavioral status exam with clinical assessment
96118 Neuropsychological Testing per hour
96119 Neuropsych Testing Admin by Technician per hour
96120 Neuropsych Testing Admin by Computer per occurrence
H0035 Mental health partial hospitalization, treatment, less than 24 hours
H2037 Developmental delay prevention activities, dependent child of client, per 15 minutes
T2027 Specialized child care, waiver; per 15 minutes
T2036 Therapeutic camping, overnight, waiver; each session
T2037 Therapeutic camping, day, waiver; each session
For standard outpatient services, WellCare will continue to use our outlier management practice to monitor and review appropriate utilization of routine outpatient therapy services. This means we will be reviewing your claims data regularly to identify patterns of service that are at variance with your peers. In addition, based on our current member utilization experience we have set a visit threshold of 20 units per year that, if exceeded, will trigger a request for clinical review to determine the medical necessity of additional units.
Procedure codes considered routine include:
90832 Psychotherapy, 30 minutes
90834 Psychotherapy, 45 minutes
90837 Psychotherapy, 60 minutes
90839 Psychotherapy for Crisis, first 60 minutes
90846 Family Psychotherapy, without patient present
90847 Family Psychotherapy, 45 minutes
90849 Multiple-Family Group Psychotherapy
90853 Group Psychotherapy
For psychological and neuropsychological testing, 5 hours will trigger a request for clinical review to determine the medical necessity of additional testing (96101, 96102, 96103, 96116, 96118, 96119, and 96120).
For all HCPC codes (“H” codes), 200 Units Total of all HCPC Series Codes will trigger a request for clinical review to determine the medical necessity of additional HCPC units.